Account Information Note: Red fields are required.
 
.........................................................................................................................................................................

Acct Name/Location

Account #

 

Mailing Address
(If blank, will mail to address on file)

 
Phone Number  
E-Mail Address   
Contact Person     

Patient Info

Patient Name
Tray  

Frame

A B ED DBL
 
Frame Eye Size
FrameName 

 
.........................................................................................................................................................................
   
FrameManufacture
FrameType
RX SPH CYL AXIS PRISM BASE OC HGT    
OD     
OS     


ADD SEG HT DIST/
DPD
NEAR
PD
  TOT DEC    
OD       
OS       
Lenses
 

Treatments Y / N
RLX/SS.....
Foundation.
UV.............

Photochromic
or Polarized
Grey......... Brown
Transition..
SunSensor
InstaShade
Polarized...
PGX.........
None..............


Material
(Select One)
RLX/SS







Glass

Type ................
(Select One)






VIP


--- ( EZ Fit )

--- ( EZ Fit Mini )







Adaptar

.......................







Other-Specify

 
.........................................................................................................................................................................
 
 
AR/Coating


ard/Slick
Carat Advantage
Pelican AR




No Mirror Coating

Tint




   
     
Special Instructions  

Shipping Information




UPS